Global Journal of Health Science; Vol. 5, No.

4; 2013
ISSN 1916-9736 E-ISSN 1916-9744
Published by Canadian Center of Science and Education

Health-Risk Factors and the Prevalence of Hypertension:

Cross-Sectional Findings from a National Cohort of 87 143 Thai Open
University Students
Prasutr Thawornchaisit1, Ferdinandus de Looze1, Christopher M Reid2, Sam-ang Seubsman3, Adrian Sleigh4 &
Thai Cohort Study Team*
1
School of Medicine, University of Queensland, Australia
2
School of Public Health and Preventive Medicine, Monash University, Australia
3
School of Human Ecology, Sukhothai Thammathirat Open University, Thailand
4
National Centre for Epidemiology and Population Health, ANU College of Medicine, Biology and
Environment, The Australian National University, Australia
Correspondence: Prasutr Thawornchaisit, School of Medicine, Faculty of Health Science, University of
Queensland, 288 Herston Road, Herston, Brisbane, QLD, 4006 Australia and Department of Medicine, Lerdsin
Hospital, Silom road, Bangrak, Bangkok 10500, Thailand. Tel: 66-2585-8015. E-mail: prasutt@yahoo.com
Thai Cohort Study Team*
Thailand: Jaruwan Chokhanapitak, Suttanit Hounthasarn, Suwanee Khamman, Daoruang Pandee, Suttinan
Pangsap, Tippawan Prapamontol, Janya Puengson, Sam-ang Seubsman, Boonchai Somboonsook, Nintita
Sripaiboonkij, Pathumvadee Somsamai, Prasutr Thawornchaisit, Duangkae Vilainerun, Wanee
Wimonwattanaphan, Cha-aim Pachanee, Arunrat Tangmunkongvorakul, Benjawan Tawatsupa, Wimalin
Rimpeekool.
Australia: Chris Bain, Emily Banks, Cathy Banwell, Bruce Caldwell, Gordon Carmichael, Tarie Dellora, Jane
Dixon, Sharon Friel, David Harley, Matthew Kelly, Tord Kjellstrom, Lynette Lim, Anthony McMichael, Tanya
Mark, Adrian Sleigh, Lyndall Strazdins, Vasoontara Yiengprugsawan, Susan Jordan, Janneke Berecki-Gisolf,
Rod McClure.

Received: March 10, 2013 Accepted: March 29, 2013 Online Published: May 1, 2013
doi:10.5539/gjhs.v5n4p126 URL: http://dx.doi.org/10.5539/gjhs.v5n4p126

This study was supported by the International Collaborative Research Grants Scheme with joint grants from the
Wellcome Trust UK (GR071587MA) and the Australian National Health and Medical Research Council
(268055), and by a global health grant from the NHMRC (585426)

The authors declare that there are no conflicts of interest

Abstract
Background: Thailand is undergoing a health-risk transition which increases chronic diseases, particularly
hypertension, as a result of a rapid transition from a developing to a developed country. This study analyzes the
effect of health-risk factors such as demography, socioeconomic status (SES) and body mass index (BMI) on the
prevalence of hypertension. Methods: This was a cross-sectional analysis using data obtained in 2005 from 87
143 Sukhothai Thammathirat Open University (STOU) students participating in the Thai Cohort Study (mean age
30.5 years, 54.7% female). Adjusted odds ratios of the association between risk factors and hypertension were
analysed across two age groups by sex, after controlling for the confounding factors such as SES and BMI.
Results: The prevalence of hypertension in men was approximately twice as high as that in women (6.9% vs
2.6%). Hypertension was associated with ageing, a lower education attainment, a higher BMI and having
underlying diseases in both sexes. In men, hypertension was associated with being single, having a high income,
spending more time on screens (TV & PC), cigarette smoking and drinking alcohol. In women, it was directly
correlated with instant and roasted or smoked food consumption. Conclusions: Hypertension was highly

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associated with obesity and having underlying disease. The Thai health-risk transition is in a later stage. Thais
should now be educated about the danger of high blood pressure and the protective power of a low fat and low
salt diet, and a normal BMI. Cessation of smoking and moderation in alcohol intake should be promoted.
Keywords: hypertension, SES, BMI, underlying diseases, smoking, drinking, Thailand
1. Introduction
Hypertension is a major public health challenge with its prevalence rising alarmingly worldwide (Kearney et al.,
2005; Kearney, Whelton, Reynolds, Whelton, & He, 2004). It is associated with increased risk of stroke and
ischemic heart disease which are major causes of global mortality, affecting low, middle and high income
countries (Lawes, Vander Hoorn, & Rodgers, 2008); 62% of strokes and 49% of cardiovascular diseases are
attributable to hypertension (F. J. He & MacGregor, 2007). In 2001, hypertension contributed to 7.6 million
deaths (13.5% of total global mortality) and 92 million disability-adjusted life years (DALYs) (J. He & Whelton,
1997; Lawes et al., 2008).
These global hypertension trends are presenting a new challenge in middle-income countries experiencing a
transition to greater longevity and chronic diseases. For example the prevalence of hypertension in Thai adults in
1991 was 5% but by 2004 it had risen to 21%, with 10 million people affected (Aekplakorn et al., 2008;
Aekplakorn et al., 2012; Leelacharas, 2009). At present hypertension is still increasing in Thailand due to ageing,
rising obesity and in association with rising prevalence of high blood lipids levels in the population (Banwell et
al., 2009; Porapakkham, Pattaraarchachai, & Aekplakorn, 2008; Sleigh, Seubsman, & Bain, 2008). The
proportion of the Thai population aged over 60 years rapidly increased from 9.5% in 2000 to 12.6% in 2010 as a
result of improvements in public health (Porapakkham et al., 2008).
Urbanisation is also underway and in recent decades, rapid socio-economic growth encouraged 32% of Thais to
migrate from rural to urban areas joining the 20% of Thais who had always lived in cities (L. Y. L. Lim et al.,
2009). Urban Thais tend to have less healthy diets (more “junk” food) and less physical activity with a more
sedentary life-style than their rural counterparts (L. Y. L. Lim et al., 2009). As a consequence, urbanisation is an
important risk factor for obesity (Banwell et al., 2009). With around half of all Thais living in an urban area, 15%
of the population is overweight (Asian standard body mass index (BMI) >23-24.9) and 16% is obese (BMI>25)
(Banwell et al., 2009). The prevalence of overweight and obesity in educated subgroups is lower than the general
population, especially for females (Banwell et al., 2009). Overall, among Thai adults, females have a higher
prevalence of excess weight than males, with the most recent estimates showing 54% of females and 41% of
males affected (Aekplakorn et al., 2007).
Multiple interrelated risk factors for hypertension are well documented and include ageing, obesity, diabetes
mellitus, hyperlipidaemia (Messerli, Williams, & Ritz, 2007), physical inactivity (Kokkinos et al., 2006), kidney
disease (Coffman & Crowley, 2008), high salt consumption (Ritz, 2010), alcohol consumption (Zilkens et al.,
2005), smoking, male sex, and genetic influences (Kannel, 2009). The prevalence of hypertension increases with
age in both sexes (Lloyd-Jones et al., 2009). Age is an independent predictor of future hypertension and is
directly correlated with rising blood pressure (Mundal et al., 1997) from a gradual increase in peripheral vascular
resistance with ageing (Franklin et al., 1997). The risk of hypertension in males and females gradually increases
with increasing BMI (Meng et al., 2011). Diabetes mellitus is an important risk factor for hypertension
development (Hsia et al., 2007) since it accelerates the loss of large arterial compliance leading to increased
pulse and systolic pressure (Tozawa et al., 2002). There have been many reports linking sodium intake to
hypertension prevalence and risk in both Western and Asian populations (Chien et al., 2008; Geleijnse, Kok, &
Grobbee, 2004; Intersalt Cooperative Research Group, 1988; Sacks et al., 2001; Sun et al., 2008; Zhang, Qin,
Liu, & Wang, 2010).
Thais need to understand their own risk factors for hypertension in order to put the global knowledge of
hypertension into local perspective. To date, research on risk factors for hypertension among the Thai population
has been restricted to specific geographical zones or limited in overall scope (Aekplakorn et al., 2012; Lwin Mm,
Tassanee, Oranut, & Chaweewon, 2011; Puavilai et al., 2011; Sitthi-Amorn, Chandraprasert, Bunnag, &
Plengvidhya, 1989; Vathesatogkit et al., 2012). Our large nationwide study enables examination of links among
a wide array of health-risk factors and prevalent hypertension. The data are from the Thai Cohort Study, a large
national cohort focused on understanding the health-risk transition in Thailand (Sleigh et al, 2008). It examines
the relative importance of many risk factors associated with emerging chronic diseases in Thailand. Our
hypertension analysis presented here includes assessment of socio-demography, smoking and drinking, dietary
preferences, sedentary behaviour, planned and incidental exercise – elements of the overarching health-risk
transition and expected to influence the occurrence of hypertension.

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2. Methods
2.1 Data and Study Population
The Thai Cohort Study (TCS) includes 87 143 distance-learning students enrolled at Sukhothai Thammathirat
Open University (STOU) who completed a 20-page mail-out baseline survey in 2005. Details on overall
methodology have been reported elsewhere (S. Seubsman, Yiengprugsawan, Sleigh, & Thai Cohort Study, 2012;
Sleigh et al., 2008). Respondents were aged from 15 to 87 years (mean age 30.5 years) and resided in all areas of
Thailand. They represented well the student body at STOU, and the adult Thai population, for geographic
distribution, income, age, ethnicity, religion and (modest) socio-economic status (Sleigh et al., 2008). Health-risk
factors measured and analysed for their association with chronic diseases were shown to represent the health-risk
transition underway in Thailand, following the eco-social model adopted for TCS (Sleigh et al., 2008).
Baseline questions focused on demography, socio-economic status (SES), work stress, personal health, history of
25 specific diseases including doctor-diagnosed hypertension, hearing, vision or dental impairment and usage of
health services, social networks and personal well-being, food consumption and exercise, transport, smoking and
drinking alcohol and family history.
2.2 Variables and Categories
Analyses included hypertension as a dependent variable. Independent variables investigated were: demography
including age, sex, and urbanization status; body mass index; and lifestyle factors including food preferences and
intake, physical exercise, smoking and alcohol consumption. Urbanization status was classified based on rural (R)
or urban (U) residence when aged 10-12 years old and in 2005 thus producing 4 groups: lifelong ruralites (RR),
urbanizers (RU), de-urbanizers (UR) and urbanites (UU). Body mass index (BMI) was calculated by the formula
weight (kg)/height (m)2. Asian cutoffs (Banwell et al., 2009; Kanazawa et al., 2002; S. A. Seubsman et al., 2010;
Weisell, 2002; Yiengprugsawan, Banwell, Seubsman, Sleigh, & Thai Cohort Study, 2012) were used for BMI
classification as follows: underweight (BMI <18.5), normal (18.5 to <23), overweight (23 to <25), or obese
(≥25).
Dietary assessment was restricted to food likely to be affected by the health-risk transition. We investigated
frequency of specific food consumption (deep fried, instant, roast or smoked, soybean products and soft drinks)
based on a five-point Likert scale ranging from less than once a month to once or more per day. Western-style
fast food consumption was recorded on a three-point scale from “less than once” to “more than three times” per
month. Fruit and vegetable consumption was recorded as serves eaten per day.
Physical activities - mild, moderate and strenuous exercise sessions for at least 20 minutes, or walking sessions
for at least 10 minutes - were recorded as four variables each ranging from never to ≥5 times per week. House
work was classified by frequency of gardening and cleaning divided into four categories ranging from ≤3 times
per month to most days. For sedentary habits respondents were divided into four categories based on how many
hours per day they regularly spent for sleeping, sitting and having screen time on television or computer.
Smoking status was classified into never, ex-smoker or current-smoker. Alcohol drinking status contained four
categories: never, ex-drinker, occasional drinker or current-drinker.
2.3 Statistical Analyses
All analyses were performed using SPSS. The prevalence of hypertension and its 95% confidence interval (CI)
in the cohort was calculated for each category of all variables. To minimise demographic confounding
participants were separated into two groups by sex, and each group was stratified into two age groups, those ≤40
years and those aged > 40. Odds ratios (ORs) and their 95% confidence intervals were calculated for the
association of hypertension with each investigated health-risk factor using bivariate logistic regression. A
P-value of <5% was used as the criterion for statistical significance. Adjusted ORs were calculated using
multivariable logistic regression models to control for confounding. Adjusting (confounding) variables were
chosen because they demonstrated a significant association with hypertension on bivariate analysis. These
variables were age, marital status, SES, BMI, physical activities, underlying diseases and personal behaviours,
cigarette smoking and alcohol drinking.
3. Results
3.1 Study Population
Of the 200 000 students approached to participate in the study, 87 134 (44%) signed the consent forms and
completed the questionnaires; 55% of respondents were female. The responding students represented well the
social geography, socio-economic status and field of study of the Open University student body (S. Seubsman et

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al., 2012). Table 1 outlines the socio-demographic characteristics of study participants. The majority of
participants were aged ≤ 40y with females being slightly younger than males (median 27 vs 31 years). About
half of the study population resided in urban areas. The highest proportion of males and females lived in the
Central and North-eastern regions respectively. Females had a moderately higher educational attainment than
males while males had a higher monthly income than females. However, over half of the student population had
a monthly income of less than US$250. The distribution of household assets for males and females was similar.
The study population was younger, slightly more urban and had achieved a higher education attainment than the
general Thai population. However, as mentioned in the Methods above, the cohort represents well the Thai
population for an array of socio-demographic attributes.
3.2 Prevalence of Factors associated with Hypertension
Overall, the prevalence of doctor-diagnosed hypertension reported by cohort members was 4.6% (6.9% of males
and 2.6% of females). In both sexes, the proportion of those with hypertension increased with increasing age.
Marriage or having a partner decreased the prevalence of hypertension in males, while in younger females the
prevalence increased. In both younger and older males and females, a previous university degree was associated
with a lower prevalence of hypertension.
The prevalence of hypertension increased with an increase of personal monthly income in all and older males.
However, income had no influence on the prevalence of hypertension in females. In all groups, the prevalence of
hypertension increased with an increased BMI with 11.9% of those in the obese category having a diagnosis of
hypertension.
The prevalence of hypertension inversely related to the frequency of house work or gardening, especially for
older males. Sedentariness was associated with increased prevalence: all males had higher prevalence of
hypertension with more screen time. In contrast, sedentary activity had no association with hypertension in
females.
Tables 2 and 3 reveal that the prevalence of hypertension increased in both men and women who had type 2
diabetes and high blood lipids. Hypertension was also more prevalent in all groups of participants who had
reported kidney disease, except in older females. In men, ex-smokers had a higher prevalence of hypertension
than non-smokers while in women, smoking had no influence on hypertension. The prevalence of hypertension
increased in all and younger males who drank alcohol while it decreased in the older males. In younger females,
the prevalence of hypertension increased with an increase of alcohol drinking status whereas in the older females,
it decreased. In all and younger females, the prevalence of hypertension had a direct association with the
frequency of instant and roasted or smoked food consumption. Older males who consumed more instant food
(3-6 times/wk) had a higher prevalence of hypertension than their counterpart who consumed less (<1time/m).
3.3 Factors not associated with Hypertension (Data not Shown)
In both males and females, factors that were not independently and statistically significantly related to the
prevalence of hypertension were urbanization status, household assets, sleeping and sitting time, physical
activities, and food consumption habits including deep fried food, soft drink, Western fast food, fruit, vegetables
and soy products.
In males, roasted or smoked foods consumption had no effect on hypertension. In females, the factors that had no
association with hypertension were personal monthly income, housework or gardening, television and computer
watching time and cigarette smoking.

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Table 1. Socio-demographic characteristics of the 87143 participants in the Thai Cohort Study, 2005
Factor Male Female Difference
n % n % P-valuea
Demographic data
Participants 39485 45.3 47658 54.7 <0.0001
Mean age-years (SD) 32.24 (8.8) 29.07 (7.5) <0.0001b
Age group (years) <0.0001
≤30 19420 49.2 30831 64.7
31-40 12993 32.9 12534 26.3
>40 7068 17.9 4287 9.0
Marital status (married/partnered) <0.0001
No 17941 46.8 27539 62.2
Yes 20392 53.2 18713 37.8
Regions <0.0001
Bangkok 5715 14.6 9148 19.3
Central 8867 22.7 12299 26.0
North 7659 19.6 8095 17.1
North-east 9554 24.4 8484 17.9
East 2397 6.1 2930 6.2
South 4933 12.6 6361 13.4
c
Urbanization status <0.0001
Rural–rural (RR) 17607 45.3 20137 42.7
Rural–urban (RU) 12619 32.4 14814 31.4
Urban–rural (UR) 1699 4.4 2008 4.3
Urban–urban (UU) 6978 17.9 10173 21.6
Socioeconomic status
Education level <0.0001
High school 21750 55.1 20703 43.5
Diploma 8903 22.6 14565 30.6
University 8732 22.1 12253 25.8
Personal monthly income (baht) d <0.0001
≤7000 13609 35.4 22026 47.4
7001–10000 8821 22.9 10977 23.6
10001–20000 10921 28.4 9648 20.8
>20000 5152 13.4 3803 8.2
Household assetse (baht) <0.0001
Low 15911 40.5 19271 40.6
Medium 12331 31.4 14271 30.1
High 11024 28.1 13887 29.3
a
Chi-square test bunpaired t test c
Location of residence (rural, R, or urban, U) at age 10-12 years and in 2005 d
At the
e
time of the survey in 2005, US$1 = 42 Thai baht Replacement value in Thai baht, divided into 3 groups: low ≤30,000,
medium 30,001-60,000 and high >60,000

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Table 2. Prevalence of hypertension and significant risk factors in male participants

All males Younger males Older males
HT(n) %Preva (95% CI) AORsb(95% CI) AORsb(95% CI) AORsb(95% CI)
Participants 2720 6.9 (6.6-7.1)
Demography
Age group
≤30 y 629 3.2 (3.0-3.5) 1
31-40 y 872 6.7 (6.3-7.1) 1.38 (1.21-1.58)
>40 y 1218 17.2 (16.4-18.1) 2.87 (2.47-3.33)
P-trend <0.0001
Marital status (married/partnered)
No 759 4.2 (3.9-4.5) 1 1 1
Yes 1880 9.2 (8.8-9.6) 0.88 (0.78-0.99) 1.0 (0.88-1.14) 0.94 (0.72-1.23)
Socio-economic status
Education level
High school 1443 6.6 (6.3-7.0) 1 1 1
Diploma 585 6.6 (6.1-7.1) 1.05 (0.93-1.17) 0.96 (0.83-1.1) 1.06 (0.87-1.28)
University 682 7.8 (7.3-8.4) 0.87 (0.78-0.98) 0.82 (0.7-0.96) 0.9 (0.76-1.07)
P-trend <0.032 <0.016 0.313
Personal monthly income (baht) c
≤7000 541 4.0 (3.7-4.3) 1 1 1
7001-10000 470 5.3 (4.9-5.8) 1.18 (1.02-1.36) 1.17 (0.99-1.37) 1.39 (0.98-1.96)
10001-20000 912 8.4 (7.8-8.9) 1.13 (0.98-1.30) 1.26 (1.06-1.49) 1.3 (0.98-1.73)
>20000 737 14.3 (13.4-15.3) 1.34 (1.13-1.59) 1.16 (0.91-1.47) 1.7 (1.3-2.35)
P-trend <0.002 0.075 <0.0001
BMI classificationd
Underweight 47 2.0 (1.42-2.6) 0.62 (0.45-0.86) 0.61 (0.42-0.87) 0.56 (0.26-1.24)
(BMI <18.5)
Normal 739 3.8 (3.6-4.1) 1 1 1
(18.5≤BMI<23)
Overweight 623 7.4 (6.8-8.0) 1.42 (1.26-1.61) 1.5 (1.28-1.75) 1.38 (1.13-1.7)
(23 ≤ BMI <25)
Obese 1242 14.0 (13.3-14.8) 2.41 (2.16-2.69) 2.66 (2.31-3.06) 2.23 (1.85-2.67)
(BMI ≥25)
P-trend <0.0001 <0.0001 <0.0001
Sedentary habits
House work/gardening
Most days 900 6.6 (6.2-7.0) 1 1 1
3-4 times/wk 362 6.8 (6.1-7.5) 1.13 (0.98-1.31) 1.1 (0.92-1.31) 1.16 (0.92-1.47)
1-2 times/wk 734 6.8 (6.4-7.3) 1.16 (1.03-1.30) 1.02 (0.88-1.19) 1.37 (1.13-1.66)
<3 times/m 683 7.5 (7.0-8.1) 1.09 (0.96-1.23) 0.97 (0.83-1.14) 1.26 (1.04-1.53)
P-trend 0.14 0.743 <0.008
TV/PC watching (hours/day)
≤1 hr 612 6.9 (6.4-7.5) 1 1 1
2 hr 820 7.1 (6.6-7.6) 0.96 (0.8-1.15) 1.11 (0.94-1.32) 0.96 (0.8-1.15)
3 hr 544 6.7 (6.2-7.3) 1.18 (0.95-1.46) 1.11 (0.93-1.34) 1.18 (0.95-1.46)
≥4 hr 695 6.8 (6.3-7.3) 1.39 (1.13-1.71) 1.2 (1.0-1.42) 1.39 (1.13-1.71)
P-trend <0.001 0.066 <0.001
Underlying diseases
Diabetes mellitus type 2
No 2500 6.4 (6.2-6.7) 1 1 1
Yes 220 41.7 (37.5-46.0) 3.63 (2.94-4.49) 4.37 (3.0-6.36) 3.19 (2.47-4.12)
High lipids
No 1748 5.0 (4.8-5.3) 1 1 1
Yes 972 20.8 (19.6-21.9) 2.38 (2.14-2.65) 3.15 (2.72-3.66) 1.85 (1.6-2.15)

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Kidney diseases
No 2557 6.6 (6.4-6.9) 1 1 1
Yes 163 16.3 (14.0-18.6) 2.16 (1.75-2.66) 2.64 (2.02-3.45) 1.55 (1.11-2.15)
Personal behaviours
Smoking status
Never 990 5.6 (5.3-6.0) 1 1 1
Ex-smoker 1152 8.9 (8.4-9.4) 1.21 (1.09-1.34) 1.21 (1.06-1.39) 1.25 (1.06-1.48)
Cur-smokere 525 6.5 (6.0-7.1) 1.04 (0.92-1.18) 1.0 (0.85-1.17) 1.14 (0.92-1.41)
P-trend 0.283 0.952 0.741
Drinking status
Never 224 5.4 (4.7-6.1) 1 1 1
Ex-drinker 393 8.9 (8.0-9.7) 1.26 (1.03-1.54) 1.45 (1.1-1.91) 1.0 (0.74-1.35)
Occ – drinkerf 1681 6.3 (6.0-6.6) 0.99 (0.84-1.17) 1.25 (1.0-1.57) 0.67 (0.51-0.88)
Reg – drinkerg 391 10.1 (9.2-11.1) 1.33 (1.08-1.63) 1.58 (1.21-2.08) 1.02 (0.74-1.41)
P-trend 0.084 0.068 0.232
Food consumption habit
Instant food
<1 time/m 713 9.1 (8.5-9.7) 1 1 1
1-3 times/m 1018 7.0 (6.6-7.4) 0.99 (0.88-1.11) 1.09 (0.92-1.29) 0.88 (0.75-1.04)
1-2 times/wk 604 6.0 (5.5-6.4) 1.06 (0.93-1.21) 1.08 (0.9-1.29) 1.04 (0.85-1.29)
3-6 times/wk 310 5.5 (4.9-6.1) 1.14 (0.96-1.34) 1.02 (0.83-1.26) 1.65 (1.23-2.21)
≥1 times/d 51 4.8 (3.5-6.1) 1.04 (0.73-1.47) 1.2 (0.83-1.75) 0.36 (0.12-1.06)
P-trend 0.161 0.706 0.188
a
Prevalence of Hypertension bAdjusted Odd ratios were from logistic regression models of hypertension adjusted for age,
marital status, socioeconomic status, BMI classification, physical activities, underlying diseases, and personal behaviours
c
In 2005 US$1 = 42 Thai baht dAsian standard BMI classification eCurrent-smoker fOccasional drinker gRegular
drinker

Table 3. Prevalence of hypertension and significant risk factors in female participants

All females Younger females Older females
HT(n) %Preva (95%CI) AORsb(95% CI) AORsb(95% CI) AORsb(95% CI)
Participants 1250 2.6 (2.48-2.77)
Demography
Age group
≤30 y 532 1.7 (1.6-1.9) 1
31-40 y 359 2.9 (2.6-3.2) 1.52 (1.29-1.8)
>40 y 359 8.4 (7.5-9.2) 3.77 (3.07-4.61)
P-trend <0.0001
Marital status (married/partnered)
No 564 2.1 (1.9-2.2) 1 1 1
Yes 650 3.5 (3.2-3.7) 1 (0.88-1.16) 1.19 (1.02-1.38) 0.94 (0.71-1.26)
Education level
High school 579 2.8 (2.6-3.0) 1 1 1
Diploma 389 2.7 (2.4-2.9) 1.02 (0.88-1.18) 0.95 (0.80-1.12) 1.06(0.78-1.44)
University 277 2.3 (2.0-2.5) 0.7 (0.59-0.83) 0.66 (0.53-0.81) 0.8 (0.59-1.1)
P-trend <0.0001 <0.0001 0.248
BMI classificationc
Underweight 142 1.4 (1.2-1.6) 0.83 (0.67-1.02) 0.8 (0.45-1.01) 0.57 (0.23-1.44)
(BMI<18.5)
Normal (18.5≤BMI<23) 556 2.0 (1.8-2.2) 1 1 1
Overweight(23≤BMI<25) 162 3.6 (3.0-4.1) 1.31 (1.07-1.6) 1.46 (0.97-2.24) 1.14 (0.8-1.64)
Obese (BMI≥25) 376 8.0 (7.2-8.8) 3.1 (2.66-3.61) 3.05 (2.05-3.99) 3.3 (2.48-4.38)
P-trend <0.0001 <0.0001 <0.0001

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Underlying diseases
Diabetes mellitus type 2
No 1194 2.5 (2.4-2.7) 1 1 1
Yes 56 26.9 (20.9-33.0) 5.68 (3.94-8.21) 7.02 (4.28-11.51) 4.19 (2.42-7.24)
High lipids
No 990 2.2 (2.1-2.4) 1 1 1
Yes 260 8.9 (7.9-10.0) 2.4 (2.02-2.86) 2.77 (2.2-3.48) 2.08 (1.6-2.7)
Kidney diseases
No 1155 2.5 (2.4-2.6) 1 1 1
Yes 95 7.4 (6.0-8.8) 3.0 (2.35-3.83) 3.36 (2.59-4.36) 1.41 (0.71-2.81)
Personal behaviours
Drinking status
Never 481 2.6 (2.4-2.8) 1 1 1
Ex-drinker 107 3.2 (2.6-3.9) 1.14 (0.89-1.45) 1.28 (0.97-1.69) 0.84 (0.49-1.42)
Occ-drinkerd 633 2.6 (2.4-2.8) 1.08 (0.94-1.23) 1.25 (1.06-1.46) 0.72 (0.55-0.94)
Reg-drinkere 12 3.9 (1.7-6.1) 1.46 (0.79-2.72) 1.81 (0.89-3.67) 0.92 (0.26-3.19)
P-trend 0.238 <0.009 <0.021
Food consumption habits
Instant food
<1 time/m 280 3.3 (3.0-3.7) 1 1 1
1-3 times/m 475 2.5 (2.3-2.8) 1.05 (0.89-1.25) 1.03 (0.83-1.29) 1.11 (0.84-1.48)
1-2 times/wk 284 2.3 (2.1-2.6) 1.11 (0.91-1.35) 1.06 (0.84-1.34) 1.11 (0.76-1.64)
3-6 times/wk 153 2.3 (2.0-2.7) 1.14 (0.9-1.44) 1.05 (0.8-1.37) 1.16 (0.65-2.08)
≥1 times/d 52 3.7 (2.7-4.7) 1.97 (1.4-2.79) 1.89 (1.31-2.73) 0.59 (0.07-5.08)
P-trend <0.012 <0.043 0.66
Roasted/smoked food
<1 time/m 229 3.0 (2.6-3.4) 1 1 1
1-3 times/m 427 2.5 (2.3-2.7) 1.03 (0.87-1.21) 1.0 (0.78-1.27) 0.93 (0.69-1.26)
1-2 times/wk 356 2.5 (2.2-2.7) 1.09 (0.91-1.31) 1.15 (0.9-1.47) 1.23 (0.86-1.75)
3-6 times/wk 187 2.7 (2.3-3.1) 1.14 (0.93-1.4) 1.29 (0.99-1.69) 0.91 (0.54-1.54)
≥1 times/d 38 3.1 (2.1-4.0) 1.39 (1.08-1.77) 1.57 (1.04-2.38) 0.49 (0.11-2.17)
P-trend <0.013 <0.004 0.906
a b
Prevalence of Hypertension Adjusted Odd ratios were calculated from logistic regression models of hypertension
adjusted for age, marital status, socioeconomic status, BMI classification, physical activities, underlying diseases, and
personal behaviours cAsian standard BMI classification dOccasional drinker eRegular drinker

4. Discussion
The TCS has been the first and largest nationwide study of a wide array of locally important risk factors for
hypertension in Thailand. Hypertension was shown to be strongly associated with age, sex, obesity and
underlying diseases including type 2 diabetes, high blood lipids and kidney disease. The observation that the risk
of hypertension increases with age for both men and women is consistent with other findings (Jo et al., 2001;
Meng et al., 2011; Rampal, Rampal, Azhar, & Rahman, 2008). Increased blood pressure with ageing reflects
reduction of large arterial compliance, causing increased arterial stiffness (Tozawa et al., 2002). This process
affects ageing Thais.
The prevalence of hypertension in males was more than twice that in females. Whilst this observation is
comparable with reports from other countries (Bhalla, Fong, Chew, & Satku, 2006; Choi et al., 2006; Rampal et
al., 2008; Su et al., 2008), the actual prevalence rates in the TCS were much lower than that of the Third
National Thai Health Examination Survey (Aekplakorn et al., 2008) in 2004 (male: 6.9% vs 23.3%; female: 2.6
vs 20.9%). Some of this discrepancy could be a result of a (double) healthy cohort effect (Last, 2001) – the
cohort constituting the STOU student body and the cohort of STOU students who joined our study would be
expected to include relatively healthy individuals. As well, the low rate of hypertension in the cohort must in part
be due to the majority of participants in the current study being younger than in the general adult population.

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Data from the National Health and Nutrition Examination Survey (NHANES) recorded that prevalence in males
was higher than that in females until 45 years of age (Lloyd-Jones et al., 2009). In Thailand, hypertension
awareness, treatment and control is higher in females than in males (Aekplakorn et al., 2012).
We found the risk of hypertension was linearly associated with BMI in all age groups of males and females
which was compatible with previous studies in Thailand (Aekplakorn et al., 2008) and in other countries (Bassett,
Fitzhugh, Crespo, King, & McLaughlin, 2002; Joshi, Lim, & Nandkumar, 2007; Pang et al., 2010; Tesfaye et al.,
2007). The association has been shown in other studies to follow a dose-response pattern (Jo et al., 2001) with
each unit of BMI increasing the risk of developing hypertension by 9% (Pang et al., 2010). Obesity is a major
risk factor for hypertension (Pang et al., 2010) and a number of potential mechanisms through which this impacts
on blood pressure have been identified. These mechanisms include endothelial dysfunction, abnormal renal
function, enhanced sympathetic nervous system (SNS) and renin-angiotensin-aldosterone system (RAAS)
activity leading to vasoconstriction and intravascular sodium and water retention (Rahmouni, Correia, Haynes, &
Mark, 2005). In Thailand, obesity is becoming a critical public health challenge with prevalence high and rising
(Aekplakorn et al., 2007). In 2004, overweight or obesity affected about one in five or one in 10 Thai adults,
respectively (Aekplakorn et al., 2007).
As with previous studies (Al Ghatrif et al., 2011; Fukui et al., 2011; Levin et al., 2010); all participants with type
2 diabetes had a higher risk of hypertension than those without diabetes. The risk increased with an increase of
fasting plasma glucose level (Aekplakorn et al., 2008). Diabetes is a predictor of hypertension (Joshi et al., 2007)
since it facilitates diabetic nephropathy (Al Ghatrif et al., 2011) and damages the arterial wall, reducing elasticity
(Levin et al., 2010). As well, hyperinsulinemia stimulates the SNS and RAAS (Levin et al., 2010).
In all age groups, high blood lipid levels were strongly associated with increased prevalence of hypertension as
has been previously reported (Fukui et al., 2011; Halperin et al., 2006; Laaksonen et al., 2008; Sesso, Buring,
Chown, Ridker, & Gaziano, 2005). A study of association between plasma lipid levels and hypertension in
women (Sesso et al., 2005) showed that the risk of elevated blood pressure rose with an increase of total
cholesterol (TC) and low-density lipoprotein cholesterol (LDL-C) level and fell with an increase of high-density
lipoprotein cholesterol (HDL-C) level. In men, hypertension risk increased with elevated triglyceride (TG) and
LDL-C and fell with high HDL-C (Laaksonen et al., 2008). High blood lipids impair endothelial function
reducing nitric oxide production leading to arteriosclerosis (Halperin et al., 2006; Laaksonen et al., 2008; Sesso
et al., 2005). Elevated blood lipids also associate with SNS overactivity (Halperin et al., 2006) and RAAS boosts
angiotensin (Laaksonen et al., 2008).
Cohort men and women with kidney disease had a significantly higher risk of hypertension than those without
kidney disease with the exception of older females. This observation may be due to the small number of older
females in the current study. Other studies have shown that the risk of hypertension directly associates with the
serum creatinine level (Johnston & Davison, 1993) and inversely associates with the glomerular filtration rate
(Buckalew et al., 1996), both reflecting the severity of kidney dysfunction. Overactivity of renin-angiotensin due
to nephropathy may enhance reabsorption of sodium at the proximal tubule (Johnston & Davison, 1993).
Married males had a significantly lower risk of hypertension than single males which was consistent with a
similar finding in Polish males (Lipowicz & Lopuszanska, 2005). Single, separated and widowed males are
significantly more likely to smoke cigarettes than married males (Molloy, Stamatakis, Randall, & Hamer, 2009).
In addition, they have significantly higher psychological distress (Molloy et al., 2009) while married men have
higher personal wellbeing indices, which include personal health and future security (Yiengprugsawan,
Seubsman, Khamman, Lim, & Sleigh, 2010). In contrast, married younger females had a significantly higher risk
of hypertension than their single counterparts. This may be because married females in the present study tended
to be more overweight and obese than single females.
Higher income TCS males were older, had higher rates of current smoking, were more likely to be overweight
and obese, and consumed more alcohol and unhealthy food. The pattern in TCS males was similar to that in
developing countries which reported that hypertension increased with an increase of family income (Meng et al.,
2011). In TCS females, income had no detected influence on hypertension. Cohort females may be more aware
of their health and well-being and they tended to maintain normal weight. Culturally Thai females are protected
against alcohol and cigarettes as both are considered unsuitable for females. They are also more likely to
regularly visit a doctor, especially now it is free of charge under universal health coverage (Yiengprugsawan,
Seubsman, Lim, Sleigh, & Thai Cohort Study, 2009). This pattern resembles that in developed countries (Bassett
et al., 2002; Bell, Thorpe, & Laveist, 2010; Jo et al., 2001; Kaplan, Huguet, Feeny, & McFarland, 2010).

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A higher level of educational attainment was associated with a lower risk of hypertension in both sexes,
especially in the younger groups, similar to the pattern in developed countries (Choi et al., 2006; Halanych et al.,
2010; Rampal et al., 2008; Schwandt, Coresh, & Hindin, 2010). People with higher education had better health
and knowledge (Min, Chang, & Balkrishnan, 2010). Household assets had no influence on hypertension in both
sexes perhaps because they depend on many factors such as individual income and educational attainment.
Higher income was likely associated with increased risk whereas higher educational achievement was related to
decreased risk.
In older males, a higher frequency of house work or gardening was associated with decreased risk of
hypertension. It was consistent with a previous study which reported that in adults yard work and gardening were
significantly associated with a decrease of blood pressure (Thurston, Sherwood, Matthews, & Blumenthal, 2011).
Spending more time on TV or PC was associated with an increased risk of hypertension in males, especially
older men, as noted in other studies (Aadahl, Kjaer, & Jorgensen, 2007; Wells et al., 2008). It may be a result of
an increase of BMI (Wells et al., 2008). Spending more time on TV or PC implies less physical activity and
increasing BMI (Aadahl et al., 2007). More alcohol, unhealthy food such as snacks and sweets and less
vegetables and fruits have also been reported (Hu et al., 2001).
In all, younger and older males, ex-smokers had a significantly higher risk of hypertension than non-smokers
which was compatible with a study of hypertension and associated factors in China (Pang et al., 2010). However
cigarette smoking had no impact on hypertension in current smoking males; this was likely due to a small
number of smokers in this study. Similarly, it had no effect on females because only a very small number of
females smoked. A study in males (Niskanen et al., 2004) reported that increased risk of hypertension was
directly associated with an increase of daily cigarette smoking in a dose-response manner. Cigarette smoking
may cause renal impairment (Niskanen et al., 2004) and atherosclerosis from vascular endothelial damage which
leads to a reduction of nitric oxide production (N. Toda & H. Toda, 2010). In this study, smoking was a risk
factor for hypertension in males.
In younger males and females, drinking alcohol increased risk of hypertension while in older males, risk
decreased. Young people tended to drink heavily more often, older people drank less. The results were similar to
other studies (Jo et al., 2001; Murray et al., 2002; Pang et al., 2010; Thadhani et al., 2002). Half a standard drink
of alcohol consumed daily significantly decreased hypertension risk but more than 2 drinks increased risk
(Halanych et al., 2010; Thadhani et al., 2002). The link between hypertension and daily alcohol consumption
was recorded as a J-shaped curve and all types of beverages such as beer, wine and liquor had a similar effect
(Thadhani et al., 2002).
Most fruit, vegetables and foods had no direct influence on hypertension. However, consumption of instant food,
generally containing high levels of fat, carbohydrate and salt, while low in fibre, vitamins and minerals, was
associated with an increased risk of hypertension in older males and in females, especially younger females.
Roasted or smoked foods, containing proteins and fat, were associated with an increased risk in females,
particularly younger women. Thais usually have food with added salty seasoning (soy or fish sauces) and sodium
consumption has a strong and direct association with hypertension (Jolly et al., 2011; Sacks et al., 2001; Stamler,
Caggiula, & Grandits, 1997; Zhang et al., 2010). In contrast, consumption of carbohydrate (Brehm, Seeley,
Daniels, & D'Alessio, 2003; Jolly et al., 2011; Ludwig et al., 1999) and proteins from meats and vegetables
(Alonso, Beunza, Bes-Rastrollo, Pajares, & Martinez-Gonzalez, 2006; Elliott et al., 2006; Sadakane et al., 2008;
Umesawa et al., 2009; Wang et al., 2008) had no effect on hypertension.
The information we present here comes from the largest cohort study in Thailand and we could evaluate many
risk factors and their effects on hypertension. Even though participants are younger, more urban and more
educated, they represent the Thai population very well for geography and many socio-demographic and
socio-economic factors (S. Seubsman et al., 2012). The results from this study will reflect the future trend of
hypertension since participants, educationally and aspirationally, represent the coming Thai generation. Cohort
participants are well educated and well acquainted with mail-based questionnaires; so the reliability of
self-report in our study is likely to be higher than that for the general population.
As it is a cross-sectional report and each variable is only measured at one point in time, it is not possible to prove
the association between causes and effects. Prevalence of self-reported hypertension may be higher in
participants having co-morbidity (including diabetes, high blood lipids or kidney disease) than those without
since they tend to visit physicians regularly for their disease follow-up. Therefore, their hypertension is more
likely to be identified by a doctor than their normal counterparts. However, it should be noted that blood pressure
measuring stations have been widely used in the Thai community over the last 5 years and virtually all Thais

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have been exposed to free blood pressure measurement. Validity of self-reported weight and height in this cohort
showed that participants were over-reporting height and under-reporting weight, but not causing a large error
(Lim, Seubsman, & Sleigh, 2009). The sensitivity and specificity of self-report for obesity (BMI ≥25 kg/m2)
were 74.2% and 97.3%, respectively, for men and 71.9% and 100% for women so overall, self-report provided
economical and valid measures of BMI (L. L. Lim et al., 2009). In addition, a validity study (n=480) of
self-reported hypertension in our cohort demonstrated that overall accuracy was 75%; sensitivity was high (82%)
and that negative reports were usually accurate (86%) (Prasutr Thawornchaisit, 2013, under review). Among
those who are well educated, we found self-report of hypertension is an economical and reasonably accurate
method of screening populations for hypertension.
In conclusion, our study has shown that the factors associated with hypertension in Thailand are similar to those
reported elsewhere. The prevalence of hypertension in males was more than twice as high as in females.
Hypertension was strongly associated with ageing, a higher BMI and having underlying diseases. It was also
moderately associated with a lower educational attainment in both sexes. It is an important emerging health
problem since Thai people are living longer and the obesity rate is rising. Public health policy should build on
the public blood pressure measuring stations and move on to more formal health education focused on education,
physical activity and healthy food consumption. In order to decrease mortality from stroke and heart disease in
Thais, a national health strategy should be developed to detect, treat and prevent hypertension.
Acknowledgements
We thank the staff at Sukhothai Thammathirat Open University (STOU) who assisted with student contact and
the STOU students who are participating in the cohort study. We also thank Dr Bandit Thinkamrop and his team
from Khon Kaen University for guiding us successfully through the complex data processing.
Ethical Considerations
Ethical approval was obtained from Sukhothai Thammathirat Open University Research and Development
Institute (protocol 0522/10) and the Australian National University Human Research Ethics Committee (protocol
2004344 and 2009570). Informed, written consent was obtained from all participants.
References
Aadahl, M., Kjaer, M., & Jorgensen, T. (2007). Influence of time spent on TV viewing and vigorous intensity
physical activity on cardiovascular biomarkers. The Inter 99 study. Eur J Cardiovasc Prev Rehabil, 14(5),
660-665. http://dx.doi.org/10.1097/HJR.0b013e3280c284c5
Aekplakorn, W., Abbott-Klafter, J., Khonputsa, P., Tatsanavivat, P., Chongsuvivatwong, V., Chariyalertsak,
S., ... Lim, S. S. (2008). Prevalence and management of prehypertension and hypertension by geographic
regions of Thailand: the Third National Health Examination Survey, 2004. J Hypertens, 26(2), 191-198.
http://dx.doi.org/10.1097/HJH.0b013e3282f09f57
Aekplakorn, W., Hogan, M. C., Chongsuvivatwong, V., Tatsanavivat, P., Chariyalertsak, S., Boonthum, A., ...
Lim, S. S. (2007). Trends in obesity and associations with education and urban or rural residence in
Thailand. Obesity (Silver Spring), 15(12), 3113-3121. http://dx.doi.org/10.1038/oby.2007.371
Aekplakorn, W., Sangthong, R., Kessomboon, P., Putwatana, P., Inthawong, R., Taneepanichskul, S., ... the
National Health Examination Survey, I. V. s. g. (2012). Changes in prevalence, awareness, treatment and
control of hypertension in Thai population, 2004-2009: Thai National Health Examination Survey III-IV. J
Hypertens, 30(9), 1734-1742. http://dx.doi.org/10.1097/HJH.0b013e3283568158
Al Ghatrif, M., Kuo, Y. F., Al Snih, S., Raji, M. A., Ray, L. A., & Markides, K. S. (2011). Trends in
hypertension prevalence, awareness, treatment and control in older Mexican Americans, 1993-2005. Ann
Epidemiol, 21(1), 15-25. http://dx.doi.org/10.1016/j.annepidem.2010.06.002
Alonso, A., Beunza, J. J., Bes-Rastrollo, M., Pajares, R. M., & Martinez-Gonzalez, M. A. (2006). Vegetable
protein and fiber from cereal are inversely associated with the risk of hypertension in a Spanish cohort.
Arch Med Res, 37(6), 778-786. http://dx.doi.org/10.1016/j.arcmed.2006.01.007
Banwell, C., Lim, L., Seubsman, S. A., Bain, C., Dixon, J., & Sleigh, A. (2009). Body mass index and
health-related behaviours in a national cohort of 87,134 Thai open university students. J Epidemiol
Community Health, 63(5), 366-372. http://dx.doi.org/10.1136/jech.2008.080820
Bassett, D. R., Jr., Fitzhugh, E. C., Crespo, C. J., King, G. A., & McLaughlin, J. E. (2002). Physical activity and
ethnic differences in hypertension prevalence in the United States. Prev Med, 34(2), 179-186.
http://dx.doi.org/10.1006/pmed.2001.0969

136
www.ccsenet.org/gjhs Global Journal of Health Science Vol. 5, No. 4; 2013

Bell, C. N., Thorpe, R. J., Jr., & Laveist, T. A. (2010). Race/Ethnicity and hypertension: the role of social
support. Am J Hypertens, 23(5), 534-540. http://dx.doi.org/10.1038/ajh.2010.28
Bhalla, V., Fong, C. W., Chew, S. K., & Satku, K. (2006). Changes in the levels of major cardiovascular risk
factors in the multi-ethnic population in Singapore after 12 years of a national non-communicable disease
intervention programme. Singapore Med J, 47(10), 841-850.
Brehm, B. J., Seeley, R. J., Daniels, S. R., & D'Alessio, D. A. (2003). A randomized trial comparing a very low
carbohydrate diet and a calorie-restricted low fat diet on body weight and cardiovascular risk factors in
healthy women. J Clin Endocrinol Metab, 88(4), 1617-1623.
Buckalew, V. M., Jr., Berg, R. L., Wang, S. R., Porush, J. G., Rauch, S., & Schulman, G. (1996). Prevalence of
hypertension in 1,795 subjects with chronic renal disease: the modification of diet in renal disease study
baseline cohort. Modification of Diet in Renal Disease Study Group. Am J Kidney Dis, 28(6), 811-821.
http://dx.doi.org/S0272638696002363 [pii]
Chien, K. L., Hsu, H. C., Chen, P. C., Su, T. C., Chang, W. T., Chen, M. F., & Lee, Y. T. (2008). Urinary
sodium and potassium excretion and risk of hypertension in Chinese: report from a community-based
cohort study in Taiwan. J Hypertens, 26(9), 1750-1756. http://dx.doi.org/10.1097/HJH.0b013e328306a0a7
Choi, K. M., Park, H. S., Han, J. H., Lee, J. S., Lee, J., Ryu, O. H., ... Kim, S. M. (2006). Prevalence of
prehypertension and hypertension in a Korean population: Korean National Health and Nutrition Survey
2001. J Hypertens, 24(8), 1515-1521. http://dx.doi.org/10.1097/01.hjh.0000239286.02389.0f
Coffman, T. M., & Crowley, S. D. (2008). Kidney in hypertension: guyton redux. Hypertension, 51(4), 811-816.
http://dx.doi.org/10.1161/HYPERTENSIONAHA.105.063636
Elliott, P., Stamler, J., Dyer, A. R., Appel, L., Dennis, B., Kesteloot, H., ... Zhou, B. (2006). Association between
protein intake and blood pressure: the INTERMAP Study. Arch Intern Med, 166(1), 79-87.
http://dx.doi.org/10.1001/archinte.166.1.79
Franklin, S. S., Gustin, W. t., Wong, N. D., Larson, M. G., Weber, M. A., Kannel, W. B., & Levy, D. (1997).
Hemodynamic patterns of age-related changes in blood pressure. The Framingham Heart Study. Circulation,
96(1), 308-315.
Fukui, M., Tanaka, M., Toda, H., Senmaru, T., Sakabe, K., Ushigome, E., ... Nakamura, N. (2011). Risk factors
for development of diabetes mellitus, hypertension and dyslipidemia. Diabetes Res Clin Pract.
http://dx.doi.org/10.1016/j.diabres.2011.07.006
Geleijnse, J. M., Kok, F. J., & Grobbee, D. E. (2004). Impact of dietary and lifestyle factors on the prevalence of
hypertension in Western populations. Eur J Public Health, 14(3), 235-239.
Halanych, J. H., Safford, M. M., Kertesz, S. G., Pletcher, M. J., Kim, Y. I., Person, S. D., ... Kiefe, C. I. (2010).
Alcohol consumption in young adults and incident hypertension: 20-year follow-up from the Coronary
Artery Risk Development in Young Adults Study. Am J Epidemiol, 171(5), 532-539.
http://dx.doi.org/10.1093/aje/kwp417
Halperin, R. O., Sesso, H. D., Ma, J., Buring, J. E., Stampfer, M. J., & Gaziano, J. M. (2006). Dyslipidemia and
the risk of incident hypertension in men. Hypertension, 47(1), 45-50.
http://dx.doi.org/10.1161/01.HYP.0000196306.42418.0e
He, F. J., & MacGregor, G. A. (2007). Salt, blood pressure and cardiovascular disease. Curr Opin Cardiol, 22(4),
298-305. http://dx.doi.org/10.1097/HCO.0b013e32814f1d8c
He, J., & Whelton, P. K. (1997). Epidemiology and prevention of hypertension. Med Clin North Am, 81(5),
1077-1097.
Hsia, J., Margolis, K. L., Eaton, C. B., Wenger, N. K., Allison, M., Wu, L., ... Black, H. R. (2007).
Prehypertension and cardiovascular disease risk in the Women's Health Initiative. Circulation, 115(7),
855-860. http://dx.doi.org/10.1161/CIRCULATIONAHA.106.656850
Hu, F. B., Leitzmann, M. F., Stampfer, M. J., Colditz, G. A., Willett, W. C., & Rimm, E. B. (2001). Physical
activity and television watching in relation to risk for type 2 diabetes mellitus in men. Arch Intern Med,
161(12), 1542-1548.
Intersalt Cooperative Research Group. (1988). Intersalt: an international study of electrolyte excretion and blood
pressure. Results for 24 hour urinary sodium and potassium excretion. Intersalt Cooperative Research
Group. BMJ, 297(6644), 319-328.

137
www.ccsenet.org/gjhs Global Journal of Health Science Vol. 5, No. 4; 2013

Jo, I., Ahn, Y., Lee, J., Shin, K. R., Lee, H. K., & Shin, C. (2001). Prevalence, awareness, treatment, control and
risk factors of hypertension in Korea: the Ansan study. J Hypertens, 19(9), 1523-1532.
Johnston, P. A., & Davison, A. M. (1993). Hypertension in adults with idiopathic glomerulonephritis and normal
serum creatinine. A report from the MRC Glomerulonephritis Registry. Nephrol Dial Transplant, 8(1),
20-24.
Jolly, S. E., Eilat-Adar, S., Wang, H., Mete, M., Fabsitz, R. R., Devereux, R. B., ... Howard, B. V. (2011).
Sex-specific associations of nutrition with hypertension and systolic blood pressure in Alaska Natives
findings from the GOCADAN study. Int J Circumpolar Health, 70(3), 254-265.
Joshi, V., Lim, J., & Nandkumar, M. (2007). Prevalence and risk factors of undetected elevated blood pressure in
an elderly Southeast Asian population. Asia Pac J Public Health, 19(2), 3-9.
Kanazawa, M., Yoshiike, N., Osaka, T., Numba, Y., Zimmet, P., & Inoue, S. (2002). Criteria and classification
of obesity in Japan and Asia-Oceania. Asia Pac J Clin Nutr, 11 Suppl 8, S732-737.
Kannel, W. B. (2009). Hypertension: reflections on risks and prognostication. Med Clin North Am, 93(3),
541-558, Table of Contents. http://dx.doi.org/10.1016/j.mcna.2009.02.006
Kaplan, M. S., Huguet, N., Feeny, D. H., & McFarland, B. H. (2010). Self-reported hypertension prevalence and
income among older adults in Canada and the United States. Soc Sci Med, 70(6), 844-849.
http://dx.doi.org/10.1016/j.socscimed.2009.11.019
Kearney, P. M., Whelton, M., Reynolds, K., Muntner, P., Whelton, P. K., & He, J. (2005). Global burden of
hypertension: analysis of worldwide data. Lancet, 365(9455), 217-223.
http://dx.doi.org/10.1016/S0140-6736(05)17741-1
Kearney, P. M., Whelton, M., Reynolds, K., Whelton, P. K., & He, J. (2004). Worldwide prevalence of
hypertension: a systematic review. J Hypertens, 22(1), 11-19.
Kokkinos, P., Pittaras, A., Manolis, A., Panagiotakos, D., Narayan, P., Manjoros, D., ... Singh, S. (2006).
Exercise capacity and 24-h blood pressure in prehypertensive men and women. Am J Hypertens, 19(3),
251-258. http://dx.doi.org/10.1016/j.amjhyper.2005.07.021
Laaksonen, D. E., Niskanen, L., Nyyssonen, K., Lakka, T. A., Laukkanen, J. A., & Salonen, J. T. (2008).
Dyslipidaemia as a predictor of hypertension in middle-aged men. Eur Heart J, 29(20), 2561-2568.
http://dx.doi.org/10.1093/eurheartj/ehn061
Last, J. M. (2001). A dictionary of epidemiology (4th ed.). New York: Oxford University Press.
Lawes, C. M., Vander Hoorn, S., & Rodgers, A. (2008). Global burden of blood-pressure-related disease, 2001.
Lancet, 371(9623), 1513-1518. http://dx.doi.org/10.1016/S0140-6736(08)60655-8
Leelacharas, S. (2009). Hypertension in Thailand. Prog Cardiovasc Nurs, 24(4), 196-198.
http://dx.doi.org/10.1111/j.1751-7117.2009.00059.x
Levin, G., Kestenbaum, B., Ida Chen, Y. D., Jacobs, D. R., Jr., Psaty, B. M., Rotter, J. I., ... de Boer, I. H. (2010).
Glucose, insulin, and incident hypertension in the multi-ethnic study of atherosclerosis. Am J Epidemiol,
172(10), 1144-1154. http://dx.doi.org/10.1093/aje/kwq266
Lim, L. L., Seubsman, S. A., & Sleigh, A. (2009). Validity of self-reported weight, height, and body mass index
among university students in Thailand: Implications for population studies of obesity in developing
countries. Popul Health Metr, 7, 15. http://dx.doi.org/10.1186/1478-7954-7-15
Lim, L. Y. L., Kjellstrom, T., Sleigh, A., Khamman, S., Seubsman, S. A., Dixon, J., & Banwell, C. (2009).
Associations between urbanisation and components of the health-risk transition in Thailand. A descriptive
study of 87,000 Thai adults. Glob Health Action, 2. http://dx.doi.org/10.3402/gha.v2i0.1914
Lipowicz, A., & Lopuszanska, M. (2005). Marital differences in blood pressure and the risk of hypertension
among Polish men. Eur J Epidemiol, 20(5), 421-427.
Lloyd-Jones, D., Adams, R., Carnethon, M., De Simone, G., Ferguson, T. B., Flegal, K., ... Hong, Y. (2009).
Heart disease and stroke statistics--2009 update: a report from the American Heart Association Statistics
Committee and Stroke Statistics Subcommittee. Circulation, 119(3), e21-181.
http://dx.doi.org/10.1161/CIRCULATIONAHA.108.191261

138
www.ccsenet.org/gjhs Global Journal of Health Science Vol. 5, No. 4; 2013

Ludwig, D. S., Pereira, M. A., Kroenke, C. H., Hilner, J. E., Van Horn, L., Slattery, M. L., & Jacobs, D. R., Jr.
(1999). Dietary fiber, weight gain, and cardiovascular disease risk factors in young adults. JAMA, 282(16),
1539-1546.
Lwin Mm, K., Tassanee, S., Oranut, P., & Chaweewon, B. (2011). Risk factors for hypertension among rural
Thais. Southeast Asian J Trop Med Public Health, 42(1), 208-217.
Meng, X. J., Dong, G. H., Wang, D., Liu, M. M., Lin, Q., Tian, S., ... Lee, Y. L. (2011). Prevalence, awareness,
treatment, control, and risk factors associated with hypertension in urban adults from 33 communities of
China: the CHPSNE study. J Hypertens, 29(7), 1303-1310.
http://dx.doi.org/10.1097/HJH.0b013e328347f79e
Messerli, F. H., Williams, B., & Ritz, E. (2007). Essential hypertension. Lancet, 370(9587), 591-603.
http://dx.doi.org/10.1016/S0140-6736(07)61299-9
Min, H., Chang, J., & Balkrishnan, R. (2010). Sociodemographic risk factors of diabetes and hypertension
prevalence in republic of Korea. Int J Hypertens, 2010, 1-6. http://dx.doi.org/10.4061/2010/410794
Molloy, G. J., Stamatakis, E., Randall, G., & Hamer, M. (2009). Marital status, gender and cardiovascular
mortality: behavioural, psychological distress and metabolic explanations. Soc Sci Med, 69(2), 223-228.
http://dx.doi.org/10.1016/j.socscimed.2009.05.010
Mundal, R., Kjeldsen, S. E., Sandvik, L., Erikssen, G., Thaulow, E., & Erikssen, J. (1997). Predictors of 7-year
changes in exercise blood pressure: effects of smoking, physical fitness and pulmonary function. J
Hypertens, 15(3), 245-249.
Murray, R. P., Connett, J. E., Tyas, S. L., Bond, R., Ekuma, O., Silversides, C. K., & Barnes, G. E. (2002).
Alcohol volume, drinking pattern, and cardiovascular disease morbidity and mortality: is there a U-shaped
function? Am J Epidemiol, 155(3), 242-248.
Niskanen, L., Laaksonen, D. E., Nyyssonen, K., Punnonen, K., Valkonen, V. P., Fuentes, R., ... Salonen, J. T.
(2004). Inflammation, abdominal obesity, and smoking as predictors of hypertension. Hypertension, 44(6),
859-865. http://dx.doi.org/10.1161/01.HYP.0000146691.51307.84
Pang, W., Li, Z., Sun, Z., Zheng, L., Zhang, X., Xu, C., ... Sun, Y. (2010). Prevalence of hypertension and
associated factors among older rural adults: results from Liaoning Province, China. Med Princ Pract, 19(1),
22-27. http://dx.doi.org/10.1159/000252830
Porapakkham, Y., Pattaraarchachai, J., & Aekplakorn, W. (2008). Prevalence, awareness, treatment and control
of hypertension and diabetes mellitus among the elderly: the 2004 National Health Examination Survey III,
Thailand. Singapore Med J, 49(11), 868-873.
Puavilai, W., Laorugpongse, D., Prompongsa, S., Sutheerapatranont, S., Siriwiwattnakul, N., Muthapongthavorn,
N., . . . Jakpechyothin, J. (2011). Prevalence and some important risk factors of hypertension in Ban Paew
District, second report. J Med Assoc Thai, 94(9), 1069-1076.
Rahmouni, K., Correia, M. L., Haynes, W. G., & Mark, A. L. (2005). Obesity-associated hypertension: new
insights into mechanisms. Hypertension, 45(1), 9-14.
http://dx.doi.org/10.1161/01.HYP.0000151325.83008.b4
Rampal, L., Rampal, S., Azhar, M. Z., & Rahman, A. R. (2008). Prevalence, awareness, treatment and control of
hypertension in Malaysia: a national study of 16,440 subjects. Public Health, 122(1), 11-18.
http://dx.doi.org/10.1016/j.puhe.2007.05.008
Ritz, E. (2010). Salt and hypertension. Nephrology (Carlton), 15 Suppl 2, 49-52.
http://dx.doi.org/10.1111/j.1440-1797.2010.01311.x
Sacks, F. M., Svetkey, L. P., Vollmer, W. M., Appel, L. J., Bray, G. A., Harsha, D., ... Lin, P. H. (2001). Effects
on blood pressure of reduced dietary sodium and the Dietary Approaches to Stop Hypertension (DASH)
diet. DASH-Sodium Collaborative Research Group. N Engl J Med, 344(1), 3-10.
http://dx.doi.org/10.1056/NEJM200101043440101
Sadakane, A., Tsutsumi, A., Gotoh, T., Ishikawa, S., Ojima, T., Kario, K., ... Kayaba, K. (2008). Dietary patterns
and levels of blood pressure and serum lipids in a Japanese population. J Epidemiol, 18(2), 58-67.
Schwandt, H. M., Coresh, J., & Hindin, M. J. (2010). Marital Status, Hypertension, Coronary Heart Disease,
Diabetes, and Death Among African American Women and Men: Incidence and Prevalence in the

139
www.ccsenet.org/gjhs Global Journal of Health Science Vol. 5, No. 4; 2013

Atherosclerosis Risk in Communities (ARIC) Study Participants. Journal of Family Issues, 31(9),
1211-1229. http://dx.doi.org/10.1177/0192513X10365487
Sesso, H. D., Buring, J. E., Chown, M. J., Ridker, P. M., & Gaziano, J. M. (2005). A prospective study of plasma
lipid levels and hypertension in women. Arch Intern Med, 165(20), 2420-2427.
http://dx.doi.org/10.1001/archinte.165.20.2420
Seubsman, S., Yiengprugsawan, V., Sleigh, A., & Thai Cohort Study, T. (2012). A Large National Thai Cohort
Study of the Health-Risk Transition based on Sukhothai Thammathirat Open University Students. ASEAN
Journal of Open Distance Learning, 4(1), 58-69.
Seubsman, S. A., Lim, L. L., Banwell, C., Sripaiboonkit, N., Kelly, M., Bain, C., & Sleigh, A. C. (2010).
Socioeconomic status, sex, and obesity in a large national cohort of 15-87-year-old open university students
in Thailand. J Epidemiol, 20(1), 13-20.
Sitthi-Amorn, C., Chandraprasert, S., Bunnag, S. C., & Plengvidhya, C. S. (1989). The prevalence and risk
factors of hypertension in Klong Toey slum and Klong Toey government apartment houses. Int J Epidemiol,
18(1), 89-94.
Sleigh, A. C., Seubsman, S. A., & Bain, C. (2008). Cohort profile: The Thai Cohort of 87,134 Open University
students. Int J Epidemiol, 37(2), 266-272. http://dx.doi.org/10.1093/ije/dym161
Stamler, J., Caggiula, A. W., & Grandits, G. A. (1997). Relation of body mass and alcohol, nutrient, fiber, and
caffeine intakes to blood pressure in the special intervention and usual care groups in the Multiple Risk
Factor Intervention Trial. Am J Clin Nutr, 65(1 Suppl), 338S-365S.
Su, T. C., Bai, C. H., Chang, H. Y., You, S. L., Chien, K. L., Chen, M. F., ... Chen, C. J. (2008). Evidence for
improved control of hypertension in Taiwan: 1993-2002. J Hypertens, 26(3), 600-606.
http://dx.doi.org/10.1097/HJH.0b013e3282f3b352
Sun, Z., Zheng, L., Xu, C., Li, J., Zhang, X., Liu, S., ... Sun, Y. (2008). Prevalence of prehypertension,
hypertension and, associated risk factors in Mongolian and Han Chinese populations in Northeast China. Int
J Cardiol, 128(2), 250-254. http://dx.doi.org/10.1016/j.ijcard.2007.08.127
Tesfaye, F., Nawi, N. G., Van Minh, H., Byass, P., Berhane, Y., Bonita, R., & Wall, S. (2007). Association
between body mass index and blood pressure across three populations in Africa and Asia. J Hum Hypertens,
21(1), 28-37. http://dx.doi.org/10.1038/sj.jhh.1002104
Thadhani, R., Camargo, C. A., Jr., Stampfer, M. J., Curhan, G. C., Willett, W. C., & Rimm, E. B. (2002).
Prospective study of moderate alcohol consumption and risk of hypertension in young women. Arch Intern
Med, 162(5), 569-574.
Thurston, R. C., Sherwood, A., Matthews, K. A., & Blumenthal, J. A. (2011). Household responsibilities,
income, and ambulatory blood pressure among working men and women. Psychosom Med, 73(2), 200-205.
http://dx.doi.org/10.1097/PSY.0b013e3182080e1a
Toda, N., & Toda, H. (2010). Nitric oxide-mediated blood flow regulation as affected by smoking and nicotine.
Eur J Pharmacol, 649(1-3), 1-13. http://dx.doi.org/10.1016/j.ejphar.2010.09.042
Tozawa, M., Iseki, K., Iseki, C., Oshiro, S., Yamazato, M., Higashiuesato, Y., ... Takishita, S. (2002). Evidence
for elevated pulse pressure in patients on chronic hemodialysis: a case-control study. Kidney Int, 62(6),
2195-2201. http://dx.doi.org/10.1046/j.1523-1755.2002.00665.x
Umesawa, M., Sato, S., Imano, H., Kitamura, A., Shimamoto, T., Yamagishi, K., ... Iso, H. (2009). Relations
between protein intake and blood pressure in Japanese men and women: the Circulatory Risk in
Communities Study (CIRCS). Am J Clin Nutr, 90(2), 377-384. http://dx.doi.org/10.3945/ajcn.2008.27109
Vathesatogkit, P., Woodward, M., Tanomsup, S., Hengprasith, B., Aekplakorn, W., Yamwong, S., & Sritara, P.
(2012). Long-term effects of socioeconomic status on incident hypertension and progression of blood
pressure. J Hypertens, 30(7), 1347-1353. http://dx.doi.org/10.1097/HJH.0b013e32835465ca
Wang, Y. F., Yancy, W. S., Jr., Yu, D., Champagne, C., Appel, L. J., & Lin, P. H. (2008). The relationship
between dietary protein intake and blood pressure: results from the PREMIER study. J Hum Hypertens,
22(11), 745-754. http://dx.doi.org/10.1038/jhh.2008.64
Weisell, R. C. (2002). Body mass index as an indicator of obesity. Asia Pac J Clin Nutr, 11 Suppl 8, S681-684.

140
www.ccsenet.org/gjhs Global Journal of Health Science Vol. 5, No. 4; 2013

Wells, J. C., Hallal, P. C., Reichert, F. F., Menezes, A. M., Araujo, C. L., & Victora, C. G. (2008). Sleep patterns
and television viewing in relation to obesity and blood pressure: evidence from an adolescent Brazilian birth
cohort. Int J Obes (Lond), 32(7), 1042-1049. http://dx.doi.org/10.1038/ijo.2008.37
Yiengprugsawan, V., Banwell, C., Seubsman, S. A., Sleigh, A. C., & Thai Cohort Study, T. (2012). Short sleep
and obesity in a large national cohort of Thai adults. BMJ Open, 2(1), e000561.
http://dx.doi.org/10.1136/bmjopen-2011-000561
Yiengprugsawan, V., Seubsman, S., Khamman, S., Lim, L. L., & Sleigh, A. C. (2010). Personal Wellbeing Index
in a National Cohort of 87,134 Thai Adults. Soc Indic Res, 98(2), 201-215.
http://dx.doi.org/10.1007/s11205-009-9542-6
Yiengprugsawan, V., Seubsman, S. A., Lim, L. L., Sleigh, A. C., & Thai Cohort Study, T. (2009). Used and
foregone health services among a cohort of 87,134 adult open university students residing throughout
Thailand. Southeast Asian J Trop Med Public Health, 40(6), 1347-1358.
Zhang, L., Qin, L. Q., Liu, A. P., & Wang, P. Y. (2010). Prevalence of risk factors for cardiovascular disease and
their associations with diet and physical activity in suburban Beijing, China. J Epidemiol, 20(3), 237-243.
Zilkens, R. R., Burke, V., Hodgson, J. M., Barden, A., Beilin, L. J., & Puddey, I. B. (2005). Red wine and beer
elevate blood pressure in normotensive men. Hypertension, 45(5), 874-879.
http://dx.doi.org/10.1161/01.HYP.0000164639.83623.76

141